=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174374276
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVIVE INFUSION BAR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2024
-----------------------------------------------------
Last Update Date | 03/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7272 HANOVER GREEN DR STE B
-----------------------------------------------------
City | MECHANICSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23111-1706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-277-9997
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7272 HANOVER GREEN DR STE B
-----------------------------------------------------
City | MECHANICSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23111-1706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-277-9997
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NP
-----------------------------------------------------
Name | SANDRA HILL
-----------------------------------------------------
Credential | AGACNP
-----------------------------------------------------
Telephone | 804-277-9992
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QI0500X
-----------------------------------------------------
Taxonomy Name | Infusion Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------